tolvaptan (generic of Jynarque) — Medical Mutual

Initial criteria

• Medication requested is being used to slow kidney function decline
• Patient age ≥ 18 years
• Liver function laboratory values (ALT, AST, bilirubin) have been reviewed and are appropriate before initiation
• Requested drug is prescribed by or under consultation with a nephrologist

Reauthorization criteria

• Medication requested is being used to slow kidney function decline
• Requested drug is prescribed by or under consultation with a nephrologist
• Patient’s kidney function (total kidney volume, albuminuria, onset or progression of hypertension, eGFR, etc.) decline has slowed and/or kidney pain has improved since treatment
• Provider is monitoring liver function monthly for the first 18 months of treatment, then every 3 months

Approval duration

initial 90 days; reauth 1 year